Medicare for All? But What Kind of Care?

The question of whether to expand Medicare has moved to the center of public attention as the 2020 presidential campaign unfolds. However, regardless of whatever changes are considered, we and the candidates must ask a more fundamental question: How can we reinvent Medicare so it is not just a method for paying medical bills, but a cost-effective, person-centered health care system that actually improves health?

Medical care does not do a good job in preventing and reversing the chronic illnesses that plague our population. And its uncontrolled costs threaten to bankrupt us. Simply expanding Medicare will do more of the same unless it changes what it pays for.

Good health is not just about diseases and treatments. Health improves by addressing the determinants of health, which are factors that medical care does not currently ask about or support. Research has repeatedly shown that roughly 80 percent of health is determined by factors outside the doctor’s office, the so-called social and behavioral determinants of health.

This means helping patients change their lifestyle, get healthy food, stop tobacco, alcohol and drug use, and have access to less-expensive, non-drug treatments. Lasting improvements in health depend on more than pills and procedures, like nutrition, income, housing, transportation and stress management. An expanded Medicare, no matter what shape it takes, must deal with these factors.

Modern medicine, so powerful in performing lifesaving miracles around acute disease, performs poorly in addressing the majority of chronic diseases. More than half of the top 25 conditions (hypertension, diabetes, obesity, chronic pain, anxiety and depression, etc.) can be mitigated and treated effectively with behavioral and integrative health approaches — nutrition and movement, health coaching, stress management, sleep, social support, and evidence-based complementary medicine such as therapeutic yoga, acupuncture and massage therapy. These approaches are less expensive than drugs and surgery if applied in time.

For example, there is good evidence that we should be treating the more than 100 million patients who suffer from chronic pain and 13 million with opioid addiction by incorporating non-pharmacological approaches into conventional medicine. But this concept has not been integrated into Medicare, despite guidelines endorsing these complementary medicine options by the American College of Physicians, the National Institutes of Health, the Centers for Disease Control and Prevention, and the Veterans Health Administration. Expanding Medicare without coverage for these approaches will not effectively stem our pain and opioid epidemics.

Medicare remains locked into paying for an outdated model of medicine that fosters expensive and late-stage treatments, extensive medical testing and heavy use of medications, even when there are less-expensive, safer and equally effective alternatives available. An example is the treatment of chronic back pain and knee pain that are increasingly widespread in our aging population.

We are spending roughly $80 billion annually for back and knee surgeries that may be unnecessary or harmful. A recent study in Pain Medicine analyzed several thousand surgeries performed in 25 clinical trials and found little to no evidence that invasive surgery was more effective than sham or placebo procedures in reducing chronic pain. Much of this treatment is paid for by Medicare when it does not pay for other less-expensive, safer and proven approaches like exercise, yoga, acupuncture and behavioral medicine.

“Medicare for All” only makes sense if it pays for a different model of health care that is patient-centered rather than physician-centered and employs an integrative team to educate and support prevention and self-care as its primary goals. In such a model, non-physician and even non-medical providers would guide a patient on his or her healing journey: Behavioral health specialists, social workers, health coaches and health navigators could generate measurable improvement in outcomes — at a far lower cost.

Consider, for example, our high incidence of obesity, diabetes and cardiovascular disease. We know that poor nutrition is a major contributor, and yet Medicare does not sufficiently cover nutritionists, healthy food and health coaches to help people prevent and reverse these costly conditions. Patient-education programs, including group visits, are effective in addressing these conditions.

Randomized, controlled clinical studies have shown that non-medical, non-pharmaceutical interventions can achieve substantial results, reducing the need for lifelong treatment with costly medications. This type of “Medicare for All” would be a fundamentally different Medicare and would transform our health care system to one that produces health and lowers costs.

Dr. Wayne Jonas is currently the executive director of Samueli Integrative Health Programs, a practicing family physician, a retired lieutenant colonel in the Medical Corps of the United States Army and previously served as the director of the Office of Alternative Medicine at the National Institutes of Health.

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